What oral contraceptive is best for decreasing heavy menstrual bleeding in a patient with anemia?

Combined Oral Contraceptives for Heavy Menstrual Bleeding in Anemia

For patients with heavy menstrual bleeding and anemia, combined oral contraceptives (COCs) containing ethinylestradiol 20 μg with levonorgestrel 100 μg are the most effective first-line oral contraceptive option to reduce bleeding and improve anemia. 1, 2

Efficacy of Combined Oral Contraceptives for Heavy Menstrual Bleeding

• COCs significantly reduce menstrual blood loss compared to placebo, with moderate-quality evidence showing that COCs can increase the chance of successful treatment from 3% to 77% in women with unacceptable heavy menstrual bleeding 1
• COCs work by inducing regular shedding of a thinner endometrium and inhibiting ovulation, which effectively reduces menstrual blood loss 1
• Low-dose COCs containing ethinylestradiol 20 μg with levonorgestrel 100 μg provide excellent contraceptive efficacy (Pearl index of 0.88) while maintaining good cycle control 2

Specific COC Recommendations for Heavy Bleeding

• First-line option: Ethinylestradiol 20 μg/levonorgestrel 100 μg COCs provide better cycle control with fewer episodes of intermenstrual bleeding compared to other low-dose formulations 3
• Second-line options: Ethinylestradiol-based COCs with other progestogens may be considered if the first-line option is not tolerated 4
• For women requiring both contraception and treatment of heavy menstrual bleeding, 17β-estradiol-based combined oral contraceptives with either acetate nomegestrol or dienogest are also effective options 4

Comparative Efficacy with Other Treatment Options

• When compared to other medical treatments for heavy menstrual bleeding:
  • COCs are less effective than levonorgestrel-releasing intrauterine systems (LNG-IUS) in reducing menstrual blood loss 1
  • There is insufficient evidence to determine comparative efficacy between COCs and NSAIDs for heavy menstrual bleeding 1

Administration Considerations

• Standard administration involves 21-24 consecutive days of active pills followed by 4-7 hormone-free days 4
• Extended or continuous regimens with fewer or no inactive pills may be considered for women who want to further reduce or eliminate menstrual bleeding 5
• If breakthrough bleeding occurs during COC use, short-term treatment options include:
  • NSAIDs for 5-7 days 4
  • For extended or continuous regimens, a hormone-free interval of 3-4 days may help manage heavy or prolonged bleeding 4

Monitoring and Follow-up

• Assess blood pressure at follow-up visits for women using COCs 4
• Monitor hemoglobin levels to evaluate improvement in anemia 4
• Evaluate for any changes in health status that might affect the safety of continued COC use 4

Potential Side Effects and Considerations

• Common side effects include headache, nausea, and breast pain 2
• Breakthrough bleeding is most common during the first few cycles and typically decreases with continued use 2, 6
• Switching between brand-name and therapeutically equivalent low-dose oral contraceptives may affect contraceptive efficacy and increase breakthrough bleeding 6

Clinical Pearl

• When prescribing COCs for heavy menstrual bleeding in anemic patients, prioritize formulations with the lowest effective dose of estrogen and progestogen that still provides adequate cycle control 5
• The ethinylestradiol 20 μg/levonorgestrel 100 μg combination offers an optimal balance of efficacy in reducing menstrual blood loss while minimizing side effects 2, 3